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VERIFICATION OF VEHICLE COMMISSARY <br />Please provide all information requested. An incomplete application may delay approval. <br />EHO I6-017 5 of 6 MFPU APPLICATION <br />7118!2008 <br />•:6- 2 i [J.�_�.T}_%4�C .i^+T� y�,�.'+4 9' "'t Y G. <br />5 WOr <br />Vehicle Name (DBA): <br />Address for Vehicle: <br />Street Address - city <br />7 <br />/� 2002, <br />1) License Plate #: , 4) Year: <br />2) Vehicle Vin #. 5) Make/Model: <br />3) State Decal* 6) Color: <br />VE}itc_��Aultur���t�Riwc�o� <br />Name: All' z) -s q� <br />Address of Owner: eV <br />Str¢et Address - city <br />The mobile food facility shall operate out of a commissary and shall report to the commissary at least once each <br />operating day for cleaning and servicing (CalCode sections 114295 &,1,14297). If the use of the commissary is <br />discontinued, the permit holder must notify this office to make the necessary changes. Failure to notify this <br />office may res It in permit revocation and penalties. <br />Si nature Vehicle O or Date <br />Business Name: M L, / G C C' - <br />Owner Name: <br />Site Address: Cu S icr_'K „v c. �f S `1' S— <br />street Address city <br />Phone: (`z-'�) I- - \l`�\° <br />I, the commissary owner, can and will provide the necessary facilities for the above mentioned vehicle at my <br />commissary as checked below: <br />❑ Liquid & solid waste disposal E]utensl washing sink Store frozen food Vehicle wash facilities <br />t2 or 3 compartments) <br />❑ Preparation of food Hat & cold water for cleaning Q Toilet & hand washing ❑ Store refrigerated food <br />❑ Store dry food/supplies ❑ Provide potable water Overnight parking Adequate electrical outlets <br />C C SCE CRENm- <br />MSI <br />a C C'N <br />nature of Commkss Owner/O erator Date S <br />Signature <br />If the commissary/food establishment is outside San Joaquin County, the local health jurisdiction must verify <br />current health permit by signing below. Commissary/food establishment is in <br />County. <br />Signature of County RE HS Date <br />EHO I6-017 5 of 6 MFPU APPLICATION <br />7118!2008 <br />